THE LATEST CONCUSSION RESEARCH

New information on concussions is published on an almost daily basis.  So much information is available sometimes that even I’m overwhelmed when trying to understand where we are with this “crisis” and making progress in its prevention, recognition and management.  The following paragraphs simply highlight what I believe to be some of the most interesting developments and stories regarding concussion in the last month.

THE FENCING RESPONSE

The AFC Championship game brought us another example of the fencing response.  It is minimally a clinical sign of brain trauma, often more specifically a concussion.  Dustin Fink on the Concussion Blog who sites THIS study from Medicine & Science in Sport and Exercise (2009) provides the best definition.  Briefly, it is an unnatural position of the arms following an impact to the head that result from forces applied to the brain stem.  Stevan Ridley clearly demonstrates the fencing response in this video.  While most statements regarding concussion recognition do not list the fencing response as a specific sign of concussion there seems to be a growing number of examples of athletes who demonstrated this response and were ultimately diagnosed with a concussion.  It is important to note that the fencing response can be an important part of the puzzle, but you can still be diagnosed with a concussion without demonstrating the fencing response.

Dave Siebert through the Bleacher Report posted an interesting analysis of the Stevan Ridley hit, click HERE to check it out.

COMPREHENSIVE STUDY ON YOUTH CONCUSSION

Earlier this month the Institute of Medicine (part of the National Academies) announced the launch of a comprehensive study of youth concussions in the United States.  According to information available on their website, the Committee on Sports-Related Concussion in Youth will consider the following topics/questions among others:

• the acute, subacute and chronic effects of single and repeated concussions
• risk factors for concussion, post concussive syndrome (PCS) and CTE
• physical and biological triggers and threshold for injury
• the effectiveness of protective equipment

The study will include elementary school age children through young adulthood, including those who serve in the military and their dependents.  The study hopes to publish its results along with recommendations to key organizations by the end of 2013.

If you would like to keep pace with the status of this project you can sign up for the project list serve through the IOM’s Committee on Sports-Related Concussion in Youth website.  For inquires you can send emails to YouthSportConcussions@nas.edu.

CONCUSSION RECOVERY TIME

According to a recent study from the University of Oregon, concussion recovery time may be longer than expected for adolescents.  Previous research on the cognitive recovery from concussions has focused on neuropsychological testing.  Lead researcher David Howell attempted to measure attention and executive function using laboratory based measures following concussion.  Executive function is simply the umbrella term for all those cognitive processes that help us problem solve, focus, switch between tasks, and control our inhibitions.  The study followed concussed adolescents for two months and demonstrated additional recovery time may be required for full recovery.  There is also hope that these laboratory tests may be helpful as part of the complement of follow up testing options after a concussion.  The study, published in Medicine and Science in Sport and Exercise, can be found HERE.  For the University Oregon announcement discussing the study results and the researchers, click HERE.

COACHES AND CONCUSSION EDUCATION

Based on current research it appears that the concussion education for coaches is beginning to have a positive effect.  According to a study published in Athletic Training & Sports Health Care (Jan./Feb. 2013) participants correctly identified more concussion-related symptoms and subscribed to fewer concussion misconceptions than did that those previously studied.  While qualified healthcare professionals should always make medical decisions, until athletic trainers (or other qualified healthcare providers) are available in all high schools coaches must continue to be educated on recognizing and referring athletes who suffer from concussions.  Coaches must also understand that following appropriate return to play guidelines is critical.  To read the full article:

Saunders, E.A., Burdette, G.T., Metzler, J.N., Joyner, A.B. & Buckley, T. (2013).  Knowledge of coaching education students regarding sports-related concussions.  Athletic Training & Sports Health Care, 5(1), 11 – 19.

Submitted by Heather L. Clemons, MS, MBA, ATC

NEW INFORMATION IN UNDERSTANDING HYPERTROPHIC CARDIOMYOPATHY

Hypertrophic cardiomyopathy (HCM) is a thickening of the heart wall (typically the left ventricle).  The cause of HCM is a genetic mutation of the cardiac sarcomere (cardiac muscle cell).  The condition is described as obstructive (70% of cases) and non-obstructive in nature.  The prevalence is 1 case in 500 – 1000 population and is the most common genetic disorder of the heart.  HCM is one of the many (and the most common) cardiac conditions that can lead to sudden cardiac arrest (SCA) in athletes.  Diagnosis of HCM in athletes is particularly challenging because athletes tend to have larger hearts and ultimately a thicker left ventricle wall because of their intense training and conditioning. 

SIGNS AND SYMPTOMS

The most common signs and symptoms for HCM include dysnea (difficulty breathing), angina, dizziness, palpitations, and syncope (fainting).  Unfortunately, many times the conditions is asymptomatic and sudden cardiac death could be the most dramatic and only symptom of HCM.  Sudden death from HCM typically occurs during or following strenuous exercise.

RISK FACTORS

First degree risk factors:

-          Family history of sudden cardiac death (<45 years old)

-          Recurrent syncope (fainting)

-          Left ventricle hypertrophy (LVH)

-          Abnormal blood pressure response during exercise

For more factors, click HERE (see page 4).

DIAGNOSIS AND TREATMENT

If you would like more specific information on the diagnosis and treatment guidelines for HCM, click HERE for the standards published in November 2011 by the American Heart Association (AHA) and the American College of Cardiology Foundation (ACCF).

CURRENT RESEARCH

The most recent information available on the topic of HCM has been provided by researchers at Stanford University.  Researchers are investigating the underlying causes of the genetic mutation of the cardiac sarcomere.  Results of this study showed that calcium dysregulation (calcium elevation) was likely to lead to HCM.  Restoration of calcium homeostasis (balance) prevented hypertrophy (enlargement of heart) and other physiological irregularities.  The authors are hopeful that these finding can lead to improved and novel treatments for the condition.  Current treatment includes adapting physical activities and in severe cases implantation of a pacemaker.  To read the press regarding the study’s publication and its potential implications, click HERE.

For other readings on HCM, check out these links:

Uptake of Cardiac Screening and Genetic Testing Among Hypertrophic and Dilated Cardiomyopathy Families

Progress With Genetic Cardiomyopathies

Athlete’s Heart of Hypertrophic Cardiomyopathy?

Exercise and Heart Disease:  From Athletes and Arrythmias to Hypertrophic Cardiomyopathy and Congenital Heart Disease

Submitted by Heather L. Clemons, MS, MBA, ATC

UNDERSTANDING CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE)

Concussions in athletes continue to be a topic that is making news all over the country.  Talk of the long-term effects of concussions will be prominent in the news, especially after the announcement that Junior Seau did have Chronic Traumatic Encephalopathy (CTE).  The term CTE has been around long enough that many people may vaguely recognize the term, but what is it in basic terms?  This entry will provide you links to some of the many articles written about Junior and help explain the basics of CTE.

JUNIOR SEAU AND CTE

According to results released by the National Institute of Health (NIH) Junior Seau did suffer from Chronic Traumatic Encephalopathy.  A review of the many pieces published related to this announcement quote his ex-wife and family as noting changes in his behavior, with wild mood swings, depression and insomnia among them.  These are key signs of CTE.  CTE is typically the long-term result of repeated blows to the head (concussions) which is why it has been particularly prevalent in former NFL players.  Recent research has also noted cases of CTE among military veterans.  As the list of individuals who suffered from CTE grows, the impetus to educate young athletes and their parents about the signs and symptoms of concussions, reporting and managing them grows as well.  Concussions are a traumatic brain injury (TBI) and CTE reminds us that there are long-term consequences for decisions we make as young people and parents.

If you would like to read more about what has been written about a Junior and his CTE diagnosis, check out these select links:

NIH Statement

ESPN

Frontline on PBS in conjunction with ESPN

Union Tribune (San Diego)

New York Times

Huffington Post

UNDERSTANDING CTE

There is a growing body of information available regarding CTE.  Some of it is easy for the general public to digest while other information is meant for researchers and other professionals who understand the nuance of the brain.  One of the more friendly sources in understanding CTE is the Center for the Study of Traumatic Encephalopathy at Boston University.

It defines CTE as:

”Chronic Traumatic Encephalopathy (CTE) is a progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic subconcussive hits to the head. CTE has been known to affect boxers since the 1920s. However, recent reports have been published of neuropathologically confirmed CTE in retired professional football players and other athletes who have a history of repetitive brain trauma. This trauma triggers progressive degeneration of the brain tissue, including the build-up of an abnormal protein called tau.  These changes in the brain can begin months, years, or even decades after the last brain trauma or end of active athletic involvement.  The brain degeneration is associated with memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and, eventually, progressive dementia”. 

      Taken from:  What is CTE?

This organization is known, in part, for its brain bank where it encourages athletes who could be at risk for CTE to donate their brains to the CSTE for further evaluation following their deaths in an effort to better understand CTE.  Currently CTE diagnosis is confirmed via the presence of tau proteins that can only be found through a biopsy of the brain following the donor's death.  This also means that much work also needs to be done  to be able to diagnose (and hopefully ultimately treat) those with CTE while they are still living with the condition.  This should give us the motivation we need to minimize the potential for brain trauma, concussive or otherwise in our efforts to decrease the potential for the development of CTE.

The list of athletes, now deceased who have confirmed cases of CTE and those that are likely living with symptoms consistent with CTE continue to grow.  The closest source to a comprehensive list of CTE suffers was recently published by the CSTE (and is linked below).  Some NFL players who are deceased include the following:  Mike Webster, Andre Waters, Lou Creekmur, John Grimsley, Terry Long, Tom McHale, Dave Duerson, and Junior Seau.  NFL players are not the only athletes who have been diagnosed with CTE in the last few years.  Others diagnosed include high school football players, hockey players, boxers, and those who serve in the military.  There are others who are suffering from ALS (Lou Gehrig's Disease), Parkinson's, and Alzheimer's who have the potential to be ultimately diagnosed with CTE, since there seems to be growing evidence of a potential connection between these neurodegenerative conditions in those who suffered repeated blows the the head.

As we learn more and more about CTE I suspect the list of names of those who are suffering from or have died because of complications related to CTE will continue to grow.  While NFL players will likely continue to be one of the biggest groups of sufferers, a number of athletes from other sports will continue to be diagnosed as well.  This is in large part connected to our growing understanding of the condition and the ability (ultimately) to recognize it in more and more individuals who have suffered various TBIs or other subconcussive blows to the head.

If you would like to read some of the key research int his area the CSTE has a list of some of the research they have published available.  Many of the articles are authored in part by Dr. Robert Cantu and Dr. Ann McKee, leaders in understanding CTE and the role of sports-related concussion.  For the original research by the CSTE, click HERE.  I recommend the following titles:

The Spectrum of Disease in Chronic Traumatic Encephalopathy (2012)

The Epidemiology of Sport-Related Concussion (2011)

Proteinpathy and Motor Neuron Disease in Chronic Traumatic Encephalopathy (2010)

For other research, feel free to search PubMed Database (public access) using the term "chronic traumatic encephalopathy in athletes."

In the end, our best defense against CTE is minimizing blows to the head over one's lifetime and preventing the disease in the first place.  This includes reporting, treating and managing concussions appropriately as well as improving equipment to help minimize the risks as much as possible.  Research has shown that those who suffer repeated sub-concussive blows to the head can also be at risk for developing CTE and no equipment is 100% effective at preventing forces to the head reaching the brain, but we should still work to get as close as we can to making CTE 100% preventable.  The warning signs of severe consequences are there, it is time to heed the warning if we have not already.  There are long-term effects to suffering from multiple concussions and repeated sub-concussive blows to the head.  It's time to ask the question, "What am I doing to decrease the injury potential in athletes I know, both in the short-term (concussions) and long-term (CTE)?"

Submitted by Heather L. Clemons, MS, MBA, ATC

Understanding Anaphylaxis

Anaphylaxis (pronounced ANA-FALL-AXIS) is a life-threatening, whole body, allergic reaction to a chemical substance (MedlinePlus).  The reaction can be swift and catastrophic if not treated quickly.  Anaphylaxis occurs when exposed to an allergen and the body becomes sensitized to it.  Subsequent exposure results in a systemic immune response, the releasing of histamine, and resulting in a typical physical response.  Signs and symptoms of a typical reaction include hives, difficulty breathing, itching, swelling of lips, face, and/or tongue among others. 

COMMON ALLERGIES

Anaphylaxis can occur in response to any allergen, but is most rare in response to pollen and other inhaled allergens.  Allergies that are more likely to cause anaphylaxis are drug allergies, food allergies, and insect bites/stings. 

According to the CDC approximately 4% - 6% of children under 18 years old suffer from food allergies.  The prevalence of allergies is also on the rise, but the reasons for the increase are unknown.  Eight types of food account for 90% of all food allergy reactions:  cow’s milk, eggs, peanuts, tree nuts (walnuts, pecans, hazelnuts, etc.), fish, shellfish, soybeans, and wheat.  The CDC has paid particular attention to limiting accidental exposure to food allergens for children in school, as this has been of particular concern.

Drug allergies result in the same allergic response from the body as other allergens.  Most often, this reaction results in a mild rash and hives, but a severe anaphylaxis reaction is possible.  According to the NIH penicillin (and other antibiotics) are the most common cause of drug allergies.  Other drug classes that can cause an allergic response are anticonvulsants, insulin (especially animal based), iodinated x-ray contrast dyes, and sulfa drugs.  Severe allergic reactions to medication, overdoses, or other negative responses to medication are referred to “adverse drug events.”  To learn more about adverse drug events in children check out the information provided by the CDC.

When stung by an insect there is typically an immediate reaction of minor redness and itching.  For most people, the reaction ends and over a period of days the bite site begins to heal.  For someone who has an anaphylactic response to an insect bite the pain, redness and swelling will likely be much more severe and the person may report difficulty breathing.  The most common insects that cause an anaphylactic response are bees, wasps, hornets, and spiders.

IMMEDIATE TREATMENT OF ANAPHYLAXIS

If you are in a situation, where you suspect anaphylaxis the most important thing you can do is call 911 and initiate the emergency medical system (EMS).  You should also assess whether or not the individual is having difficulty breathing, if so monitor ABCs (airway, breathing, and circulation) until EMS arrives and be prepared to initiate rescue breathing or CPR as necessary.  It is also important to understand what allergy may be causing the reaction so that you can provide appropriate first aid.  Here is a list of key steps for the immediate care for someone suffering for anaphylaxis:

• Activate EMS
• Assess ABCs and initiate rescue breathing and CPR as necessary
• If having difficulty breathing monitor for worsening symptoms and do not give food or drink
• If available, instruct victim (or if necessary assist victim) in administering epi-pen
• victims with known severe food or insect bite allergies may have an epi-pen available
• If reaction is because of an insect sting, remove the stinger using a stiff card (such as credit card or driver’s license, do NOT use tweezers)
• Remove any restricting clothing or jewelry around area of potential swelling to limit additional complications
• Monitor victim until EMS arrives

For more specific information on how to treat a typical allergic reaction check out the information made available by the NIH for food allergies, drug allergies and bee/insect bites.

PREVENTION OF ANAPHYLAXIS

There are many situations where people are unaware that they have an allergy until they have their first adverse reaction making prevention impossible in these cases.  For someone with a diagnosed allergy, especially a severe one, it is very important that all effort be made to avoid contact with or ingestion of the allergen.  In many cases, individuals with severe allergies are encouraged to wear a medical alert bracelet and have an epi-pen available at all times. 

How food allergies develop are not fully understood although some research shows that breast feeding infants and delaying the introduction of common allergy inducing foods to infants until their gastrointestional tracts are mature enough to handle them (this varies by food) can help decrease the likelihood of allergies.  Once an allergy becomes known, the best prevention is to avoid the food you are allergic too.

Similar to food allergies, drug allergies should be prevented by avoiding the offending medication and often, similar medications (those in the same class). 

Finally, to minimize the possibility of being stung by a bee or other insect there are several things you can do.  Most importantly, when eating outside do not hang around garbage cans or near a large number of sweet drinks or foods.  You should also avoid wearing floral perfumes and dark or floral patterned clothing.

INTERNET RESOURCES

The American Academy of Allergy, Asthma and Immunology (AAAAI)

The American College of Allergy, Asthma and Immunology (ACAAI)

Safe School and Ready to Learn:  A Comprehensive Policy Guide for Protecting Students with Life-Threatening Food Allergies

Food Allergy and Anaphylaxix:  A NASN Tool Kit

National Ag Safety Database First Aid for Bee and Insect Stings

Submitted by Heather L. Clemons, M S, MBA, ATC

Mental Health Resources for Children and Adolscents

In light of the tragic events in Newtown, Connecticut at Sandy Hook Elementary School the topics of gun control and appropriate mental health care for our nation’s young people is again at the forefront.  As the debate continues following the events in Newtown there will be many discussions about gun control legislation as well as the current mental health system in the United States.  This blog entry is not a commentary on how to prevent other tragedies through various political and social actions.  My intention is to shed some light on who to connect with and how to access resources around mental health issues for parents who have questions.  Addressing one's mental health should be as important as addressing physical ailments, but because of the stigma connected with mental health conditions this aspect of overall wellness is often overlooked. 

MENTAL HEALTH CONDITIONS:

Children and adolescents can suffer from a variety of mental health issues, just as adults.  The list of mental health concerns includes depression, anxiety disorders, personality disorders, autism, eating disorders, ADHD, and post traumatic stress disorder (PTSD), among others.  Discussing each of these disorders is beyond the scope of this post, but I will provide a few recent statistics made available by the National Institute of Mental Health (NIMH).  Further description of each condition can be found by searching the condition name on the American Psychiatric Association or American Psychological Association websites.

• The lifetime prevalence for depression in 13 – 18 year old children is 11.2%, with 3.3% of this same group having a severe depressive disorder.

• Attention Deficit-Hyperactivity Disorder (ADHD) has a lifetime prevalence of 9% in 13 – 18 year old children. 

• Anxiety disorder is the general description that includes the specific diagnosis of general anxiety disorder (GAD), obsessive-compulsive disorder, panic disorder, PTSD, and phobias.  GAD has a lifetime prevalence of 1% in 13 – 18 year old children according to the NIMH. 

MENTAL HEALTH PROVIDERS:

When seeking mental health care one of the first questions often asked is, who should I see?.  Speaking with your family physician or pediatrician is often a great place to start when looking for recommendations in your local community.  It is also helpful to understand the major types of professionals available.  You will find a brief summary of psychiatrists, psychologists and clinical social workers.  You may also have the option of counselors and marriage and family therapists depending on your specific need.

  

Psychiatrists

Psychiatrists are medical doctors (MD, DO) who graduated from a medical school and further specialized in the area of psychiatry.  This means that following medical school they complete a four-year residency in the area of psychiatry.  Some choose to specialize even further and obtain additional training.  Some specialization areas include child and adolescent, geriatric, and addition psychiatry among others.

They specialize in the diagnosis, treatment, and prevention of mental illnesses.  Psychiatrists treat both the physical and mental aspects of mental illness.  Their treatment options can range from psychotherapy (talk therapy), medications, and other treatment options.  For further information visit the American Psychiatric Association website.

Psychologists

Psychologists with a doctoral degree (PhD, PsyD, EdD), have at least seven years of education and training beyond their undergraduate education.  Psychologists have dozens of career options in research, teaching or clinical practice.  Specialties can include educational, industrial or clinical psychology among others.

The psychologists we most often think of who provide talk therapy treatment are clinical psychologists.  These psychologists have a doctoral degree and must me licensed in the state in which they work.  They typically provide treatment for people who need help coping with life issues and mental issues using a variety of theories and techniques based on the patient’s values.  Many of them are also qualified to administer and interpret a variety of tests and assessments.  Unlike psychiatrists, psychologists cannot prescribe medications.  For further information visit the American Psychological Association (APA) website.  Other associations you may wish to investigate include the Society of Clinical Psychology, Division 12 and Society of Counseling Psychology, Division 17.

Social Workers

Social workers can earn degrees at bachelors (BSW), masters (MSW) and doctorate (DSW, PhD) level, each with their own particular knowledge and competencies.  A licensed clinical social worker (LCSW) typically has two years of graduate school and internship (supervised field instruction) in the area of psychotherapy.  Other specialty areas where you will find social workers include adolescent health, aging, violence, and children, youth and family among others.

Clinical social workers provide psychotherapy (talk therapy) to patients who need help coping with life issues and mental health issues.  This is much in the same way as a psychologist.  For more information about clinical social workers and the other specialties in social work visit the National Association  of Social Workers (NASW).

To find out more information about counselors visit the American Counseling Association website.

MENTAL HEALTH RESOURCES:

Specific to Sandy Hook

Tips for talking to children about the shooting

Tips for talking to children about the shooting from APA

Tips for restoring a sense of safety after the shooting

Grief/loss resources from NASW

General Resources

Mental Health Resources from American Psychiatric Association

Mental Health Resources from American Psychological Association

National Institute of Mental Health (NIMH) child and adolescent mental health

National Alliance on Mental Illness (NAMI) Internet resource list

Submitted by Heather L. Clemons, MS, MBA, ATC